8752 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
APPLICATION & PERMIT 8752
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER 7 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
/ C PHONE
I ACrOR`s 7Y8,i0 UTLETS-SWITCHES-RECEP 10.00/1.00
no LIGHTING FIXTURES 10.00/1.00
R .s
nopREss APPLIANCES-RESIDENTIAL 4.00
S '
/PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT I PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.N SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 20.00
ANrs
ADDDRESDRESS StgNTfi 6JAp/JMOTORS SEE FEE SCH. Af
-
- SERVICECHANGE 20.00
,00 LICIT N.EU CONTRACTORS DECLARATION ,
TEMP.POLE 30.00
o u w I hereby affirm that I am licensed under provisisins of Chapter 9 ISSUANCE DATE
v, C w (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z1y1 Professions Code,and my license is in full force and effect.
z o m -11 license Class -- /T_I.i c.Number_'��/�(_a ❑ ❑ ❑
0 m H(w Dale y Contractor
a Y E y R rS rO BUILDING PERMIT
n: co n o W,'E BUILDER UECLARAT ON INFORMATION
E:
; LL I_heruby affirm that I ant exempt from the Contractor's License MISC.- REFER TO ORD
F LL o e Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT..
Code:Any city or county which requires a permit to construct,alter,
pimprove,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTE LIC.NO. ELEC.
O rt requires the applicant for such permit to file a signed statement that TOTAL,(0 J� PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of(he
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
fio
the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
n ;m by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00 r
of not more than five hundred dollars(5500).): {g
❑ I,as owner of the properly,Or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,Provided tlmt such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC:4 OUTLETS 6.00
or improvement Is sold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4 (EA
builder will have the burden of proving that he did not build or am- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON RB Other
C1 1,as owner of the Property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an Owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contractors)licensed pursumit to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ tum esennpt under Sec. ,B.&I'.C.for this WATER HEATER W/VENT 6.00
fcao.
Owner Duce WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARA'T'ION WATER TREATING EQUIP, 5.00
I hereby uftirm that have a c'crtificate of Consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a cerlitied
copy thereof(Sec.3804 Lab.C.I
Policy No. Company_r.J-j,6,41
O ❑ Certified copy is hereby funis tl d. FIRE SPRINK ENERGY T-24
z Z ,§�Certified copy is fled with the city inspection division-
F O N A p an
` 1-_C�rr� MISC.- REFER TO ORD. Y� N� Y N�
CC N/ CER'1'I I°l l'EXEM Obi WORKERS' PERMIT ISSUANCE 10'00 =FLO A.L.U.C.
W 7 COMI'EN'SATION INSURANCIi PLO.CONTE. LIC.NO. PLGV N
Z ('Phis section need not be complete) it the permit is for one TOTAL
hundred dollars(5100)or IessJ
U O 1 certify that in the perfurnmece Of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
�,Ed Date • Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NO'1'ICIi TO AI'PLICAN'I': II',utter making this Celificate Of Bx-
F Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). x HEATING UNIT (TO 100,000 B.T.U.) 6.00
Lender's Name HEATINGUNIT OVER 100,0008.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and countyCOMPI3 H.P.or 100,000 B.T.U.1 6.00 PLUMBING
ordinances and state laws relating to building construction. and BOILER-
hereby authorize representatives of this city to enter upon the BOILER-COMP IOVer,100,000 BTU)SEE FEE SCH. MECHANICAL
abovo-mentinned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against BabRities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way ccvsfe against said City consequence of the
granting of this MECH.MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature o Applic nt/C tractor Date r
INSPECTOR COPY